Here are 63 pain points to endure and overcome

During the last four years, Healthcare Purchasing News has explored just about every angle and facet surrounding radiofrequency identification and real-time location systems. Just type in "RFID" and "RTLS" into the HPN Online search engine ( www.hpnonline.com ) and read through the yards of ink HPN has dedicated to the topic since 2006, including costs, comparing options, priorities for application, return on investment and overall outlook.

But after attending several RFID/RTLS sessions in early August at Association for Healthcare Resource & Materials Management annual conference in Denver, one element seemed to need recurring visits: The so-called do-over. Think of it as "if I had to do it all over again here’s what I’d ask the vendor about," or better yet, "here’s what I’d advise you to be prepared to handle/solve/ask the vendor about."

When it comes to adopting and implementing any technology you’re bound to hit some roadblocks or speed bumps along the way.

These challenges or pain points – no matter how insignificant or irritating any nuances may be – contribute to the holistic, multi-dimensional understanding and viewpoint of the asset tracking configuration/medium of choice, whether it’s RFID, ultrasound, infrared, RuBee, ZigBee and the rest.

Some may use these challenges or pain points as go/no-go motivations (e.g., roadblocks) while others may view them as mere elements of conducting business (e.g., speed bumps).

As a result, HPN sought to highlight the challenges and pain points hospitals and other healthcare facilities may face when implementing and using RFID and RTLS technologies, as well as any actual and potential solutions available. The intent was not to discourage but to prepare with ample foresight.

HPN recruited nearly a dozen experts, including supply chain directors, information services directors, and managers of software technology suppliers to share what they’ve learned themselves or from customers about their pain points during implementation and ongoing performance of the technology.

Joel Cook, healthcare solutions marketing director, AeroScout, shared the pain points he’s uncovered, followed by the solutions.

Healthcare organizations often discover that they didn’t know what they didn’t know. Hospitals that deploy a new RTLS solution suddenly gain a significant level of visibility that they never had before. This often exposes things they didn’t know before or which they hadn’t expected. For example, when hospitals first implement our Temperature Monitoring solution, they often discover faulty refrigerators that need to be replaced that they previously thought were working fine. Or they discover that they have infusion pumps sitting idle and unused for days in one department while some staff in another department had always believed that there was a shortage. Such discoveries are valuable and an important benefit of an RTLS solution, but they uncover items that need improvement, additional attention or new processes.

Lack of standard nomenclature across departments can create frustration and extra work. Different departments within a hospital may refer to equipment by using different names. Nurses might search for "Bair Hugger," whereas the biomed team might search for "Patient Warmer," even though it’s the same item. This can cause frustration and inefficiency.

Lack of coordination across departments is an issue that can lead to delays in an implementation process. There are typically many potential stakeholders throughout a hospital in an RTLS implementation, all with different priorities and expectations. Without alignment among stakeholders, delays and inconsistencies can arise as the internal groups work in silos.

Hospitals don’t always fully anticipate the needs of future users of RTLS. For example, nursing may have patient flow needs while biomed may have equipment maintenance needs and the pharmacy may have temperature monitoring needs.

Deploying a departmental solution and later trying to extend it can lead to unnecessary expenses or may not even be possible. It’s not uncommon for one department to try to drive an RTLS implementation without factoring in the needs and use cases of other departments that may also benefit from such a solution later.

Marian Bayer, MBA, MPA, president, Cenbion’s healthcare division, and founder and principal, Aperio Visum, a consulting firm focused on improving a hospital’s use of technology to improve business management and financial performance, delineated the links between tools and users. Cenbion works with Motorola, developing software for inventory management and asset tracking that includes RFID-enabled location detection, inventory expiration management and back office integration.

As with any new technology implementation, there are always the expected and unexpected challenges. I have found that many of the challenges are more about people, rather than the technology. If you have existing issues with such things as communication, adaptability to change, accountability or level of technical proficiency, you can bet these issues are going to be exaggerated during the implementation. Having the right people on the project team and a vendor committed to your success is critical.

"There will be ongoing challenges, as is true with any technology," she added. "You really have to take on the full responsibility of making any RFID/RTLS system successful for your staff, patients and as a sound financial investment. This includes making sure the vendor delivers, or even over delivers, on the full scope of the project; ensuring staff has the necessary initial and ongoing training; building a strong, positive relationship with customer and technical support; and understanding what issues are caused by the technology and what issues are caused by the users." Some implementation challenges to avoid are:

Insufficient lead time for all hardware and software delivery.

Implementation drags on because the vendor can’t deliver the functionality that was promised, or the vendor’s attention has moved on to other clients.

The vendor has the best technology solution, but the implementation team stalls with final installation of hardware and software. 

Decrease in the staffs’ productivity due to inadequate training.

Missed opportunities to increase productivity, because existing processes/procedures were not updated to make the most of the new technology.

Bill Hendrickson, CMRP, director, supply chain logistics, contract & supply management, SSM Health Care, selected and implemented AeroScout’s infrastructure, RFID tags and MobileView application on March 30, 2009. While they experienced challenges or pain points, Hendrickson emphasized that St. Clare Health Center "has realized significant benefits with implementing the technology." They use RFID to track moveable medical equipment and perform temperature monitoring, "which saves the facility many hours of labor in manually tracking equipment and monitoring temperatures, while helping to improve equipment utilization and minimize rental costs."

Planning for system growth. Based upon an analysis of the devices to be RFID monitored, St. Clare purchased 400 tags and a license agreement that would allow for use of 500 total tags. The assumption was this would allow for 25 percent growth. Due to a higher than anticipated patient volume and increased demand for RFID monitoring, immediately a ceiling was hit regarding growth.

System calibration. The RFID infrastructure was installed during the construction of St. Clare. During trialing and initial usage of the system, the location accuracy was extremely high. For instance, devices were typically found within a few feet of where they showed on the facility map in the MobileView Tracking application.

After opening SCHC, the location accuracy degraded. In some cases, devices would show as being in a patient room but when physically located, the device would be in a different room (typically one next to the room where the device was showing being located on the Mobile View Tracking application). The accuracy could be off 10 feet or greater.

Attachment of RFID Tags. One year after installing the RFID system, St. Clare converted to a different infusion pump. The new pump was designed for space efficiency. The pumps can be used either individually or with multiple pumps as required. When used with multiple pumps, the pumps are designed to either stack or be placed in a space station.

Infusion pumps are one of the devices St. Clare tracks with RFID. The new pump design presented the challenge of where to locate the RFID tag on the pump. There was no location on the pump where the RFID tag could be placed that would not affect the ability of the pump to be stacked or positioned in a space station.

MobileView Training. Prior to go-live, training was limited to Materials Management and Facilities Management. Initial thinking was these departments would be the primary users and only departments in need of training. After go-live, it became evident the potential of the system was limited by the availability of those few trained individuals.

Installation of "choke points." To minimize costs, the installations of "choke points" were limited. Choke points allow for immediate notification when a device leaves the facility. Shortly after go-live, several devices were providing an "out-of-sight" alert. After a lot of research, it was determined that devices left the facility through exits not containing choke points. The devices exited through areas such as the receiving dock or Medical Office building entrances. One example was a pump being returned to the manufacturer for repair, and the RFID tag was inadvertently not removed.

Processes related to using RFID Technology. One of the biggest challenges was developing processes to support utilization of RFID technology. Deploying RFID technology, provides for house-wide visibility of equipment utilization. This creates opportunity to share equipment across units. This would occasionally create conflict when taking residual equipment from one unit to supply a surge in volume on another unit. The perception, of the unit where equipment was being borrowed, was that equipment is being taken from us which we may eventually need. Confidence was low that the equipment would be returned.

Sam Itani, vice president of support services, San Joaquin Community Hospital, purchased Skytron Asset Manager, powered by Awarepoint, which also manages the service and maintenance agreement.

Verify asset coverage areas. Know your true enterprise footprint and zones, especially adjacent buildings and service areas.

Vendor/IT walkthrough. Upfront planning is key to a successful installation.

Meaningful asset naming convention is critical.

Have an accurate list of how many devices you actually have in the facility.

Make sure the system is promoted and supported by senior leadership to drive adoption and process change particularly after go-live.

The Skytron Asset Manager has an Alert feature that is very useful. This feature will alert you if a device is leaving the building, if a device is leaving a specific area within the hospital, even if a refrigerator temperature is outside the set limits. The alert may be done via a pager or an email and if no one responds to that alert the system has the ability to escalate this alert to someone else. Our ongoing challenge lies in acknowledging the alert. Our staff [members] do respond to the alert but often they do not acknowledge the alert in the system. That will trigger the system to escalate this alert even though it has been taken care of.

Carolyn Ricci, senior RFID product manager, Zebra Technologies International LLC, pulled the camera back and posited more of a wide-angle view.

The first challenge is the business pain point that needs to be addressed. And this shouldn’t be a simple desire for "better tracking." Clear identification of where the blind spots are in your asset management and what degree of location accuracy should be addressed first.

Second, what metrics/goals will be tracked? Is the primary goal to increase utilization of equipment or is better inventory management and location tracking more important? The answer can be all of the above but setting the metrics of an RFID solution up front will better determine effectiveness after installation.

The third challenge is the hospital itself. Hospitals present unique challenges because unlike warehouses and retail floors, there are many floors and even more rooms. Identifying where reading should be done such as doorways or ward entrances is one issue, but deciding what degree of location identification is required also needs to be addressed. Is knowing that a respirator is somewhere on a floor enough, or is pinpointing exactly which room it is in desired?

The fourth issue is looking at the degree of criticalness of the assets. Non-critical assets, such as computer equipment or maintenance equipment, may not need location identification beyond the floor they are on, but location information of critical assets, such as ventilators, defibrillators and dialysis equipment, may need to be measured in feet vs. floors.

The last issue is the equipment tagging itself. A lot of medical equipment is metal so tagging needs to be done appropriately to prevent misreads due to the metallic interference with the reader.

Joe Pleshek, CEO and president, Terso Solutions Inc., represents a company that designs, manufactures and manages RFID-enabled enclosures to automate the management and control of high-value inventory for hospitals, manufacturers and distributors and laboratories. Terso integrates RFID-enabled Intelligent Enclosures with Data Management and 24/7 Support Services to effectively monitor product inventory any time day or night. Using secure access, each inventory transaction is automatically captured and processed in real time.

One of the biggest challenges we see is fear of the unknown from front-line hospital staff. Nurses and other hospital staff often have a well-established routine, including using index cards and sticker system to keep track of inventory. When you start to bring up RFID, there is concern about learning a new, highly technical way of doing their work.

Another challenge we see comes from hospital IT staff. Intelligent inventory systems like those from Terso require an Internet connection, and IT departments rightfully protect access to the internal network and keep a watchful eye on data that moves over their firewalls. In addition, many IT departments are wary of installing and supporting yet another piece of hardware or software onsite.

A third challenge is the perception of RFID as a "proven" technology. There are still those that feel RFID is not proven, and that the technology is not mature enough to use in a production environment. In addition, there are some concerns about accuracy.

We also see a fourth challenge being considered yet another supplier in a hospital’s supply chain. With significant investments in systems, processes, and providers, there is often a perception that it is going to be difficult to manage yet another relationship. In addition, there is some apprehension about connecting different supplier information and inventory data across different systems.

The final challenge we see is the integration of existing data across multiple applications. As with any large organization, data lives in many different systems across many different locations. The ability to share this data is a huge challenge, and one that should not be minimized. Highly visible real time data is crucial to reducing cost and controlling inventory, so it makes sense that this data is securely integrated across the organization.

Another challenge we see is the perception that an RFID inventory management system requires a complete overhaul and replacement of existing systems. There is often a significant cost associated with building out a total end-to-end solution, and many organizations believe that the only option is to replace every piece of equipment or system application. Hospitals are already facing significant pressure when it comes to making these types of purchases, and as time goes on, spending more on these types of projects will become even more difficult.

Valerie Fritz, senior vice president of marketing, Awarepoint Real-time Awareness Solutions, noted that from its customers’ standpoint, the first hurdle to overcome relates to critical success factors in making the decision to invest in RTLS.

Network coverage must be enterprise-wide. These systems are ineffective in proactive resource management if you leave holes in the infrastructure.

Room level accuracy is critical. These solutions have moved well beyond asset location tracking to true business intelligence tools and are now moving to resource management, enterprise throughput and other applications. Data generated about the relationships between tagged assets, patients, staff, and their locations requires confidence as it relates to the room in which they are occurring. Rules can range from straightforward things like an alert in response to equipment piling up in a dirty utility room or one signaling equipment rental status to sophisticated workflow mapping to improve patient flow or surgical suite utilization.

The technology must be non-invasive to deploy and require low IT maintenance. From an installation standpoint, hospitals represent a very challenging environment for most RTLS. The variety of building materials found in many hospitals, from reinforced concrete to lath and plaster, are more difficult for indoor positioning systems than commercial office space. Shielding from some imaging modalities, the variety of electro mechanical equipment and large metal carts, fluids and other consumables also create challenges to RTLS. Clinical requirements can make accessing drop ceilings and drilling in walls, along with more extensive renovations expensive and time consuming.

Ideally, the solution is truly wireless. In addition, both proprietary systems and add-ons to existing Wi-Fi systems must be evaluated based on ongoing support requirements they may put upon hospital IT departments for calibration, network security, increased network traffic and overall operational maintenance.

An interoperable, scalable solution is key. These systems typically start with enterprise asset management, but that is truly only the start. Location and condition-sensing data can be a powerful enhancement to hundreds of existing systems throughout the facility. RTLS data should be easy to share with these systems, and offer a standards-based, open [application programming interface] to assure scalability.

The business model is key. A low-risk business model that provides a month-to-month rental option allows hospitals to deploy RTLS, confirm value, and expand as needed, without a upfront capital payment commitment, or hard-wired infrastructure that may be difficult to back away from later.

From an implementation and ongoing performance standpoint with our clients, our biggest key learning is the "field of dreams" mentality doesn’t work. Just because you build it, don’t assume they’ll come. Technology is simply an enabler – people and process change are key to really getting long-term value. A business case surrounding user adoption and outcomes is vital. Oftentimes, vendors spend all their effort on selling and installing, then do some quick training – maybe – and hope. Hope is not a strategy!

Our biggest challenge as a vendor is ongoing commitment from senior leadership in assuring that process change is adopted. When this is in sync, RTLS provides incredible efficiencies, happier staff and ultimately, better patient care. RTLS can enable applications that reduce costs, but only if you use it (e.g., someone has to respond to alerts, rentals have to be centralized and tagged as they come in, entire asset categories must be managed, etc.). Also, in order to measure tangible outcomes, hospital managers must be transparent about the "before" picture. In order to get credit for the "after," clients must own up to the "before" – and that can sometimes be a challenge. But once you show them the inefficiencies and outline the "what’s in it for them," cooperation happens.

For the front line, including nurses, physicians, therapists, transporters and biomedical engineering: What’s in it for them? They need reliable access to equipment to safely deliver care. Work satisfaction is important, as is work/life balance. They need the ability to get their job done within eight hours. The lack of equipment risks their safety and the safety of their patients and their licensures. We spend a lot of time understanding the challenges and pain points of each of the constituencies we serve, and ultimately deliver value that is specific to their needs.

Skip Fisher, director of implementation and support services, RadarFind Corp., a subsidiary of TeleTracking Technologies Inc., focused on the accuracy and reliability of the data moving through the system, as opposed to the system itself. RadarFind’s Real Time Location System is based on an enterprise-wide sophisticated sensor network that automatically tracks both people and hospital equipment while supplying meaningful data used to simplify and transform common hospital processes. Intelligent RadarFind RTLS Tags attached to patient care equipment provide valuable information beyond just location. Status (clean or in-use or dirty), temperature and other hospital-critical environmental sensor readings are also detected and reported with the system.

RadarFind’s patented sensor network elements include readers that simply plug in and replicate existing hospital-grade outlets. No need to close-off patient rooms during installation. The system leverages the 900 MHz frequency band to avoid interference with and/or taxing of a hospital’s existing Wi-Fi network. A Web-based browser displays the information over the hospital’s network to computers, workstations-on-wheels or PDAs.

When implementing RadarFind for asset and patient tracking, in order for the system to perform optimally, it’s imperative that information provided by the hospital be as up to date as possible. For example, the RadarFind software uses hospital-defined locations and facility maps as part of its intuitive system. If the maps provided are inaccurate, then the software renderings will not be accurate and may cause confusion for the user.

Likewise, the physical areas of the hospital need to be defined with common nomenclature. For example, the hospital below refers to Materials Management department as MPD and the software reflects that area name.

For asset tracking, the devices listed in the system also have to be named such that nurses, biomed, materials management, environmental services staff can clearly identify the device. For example, NIBP (non-invasive blood pressure monitors) vs. BP/Vital signs monitors. The provided list of devices to be tracked by the hospital also needs to be up to date in order for an asset tree to be developed. The asset tree gives a visual rendering of how devices are organized into categories and sub-categories.

An essential component to a successful RTLS implementation also requires that hospital leaders communicate throughout the hospital that a new innovative technology will be available and how that technology will help staff in performing their work. In instances where leadership does not clearly convey the benefits of the new technology, adoption within the hospital can be hindered.

Finally, during the implementation of the RadarFind RTLS a project administrator is assigned by the hospital to oversee and coordinate various elements of the installation (i.e., working with the hospital’s IT department on installation and configuration of the RadarFind server). However, having that project administrator to continue as key coordinator (or assigning another project manager) once the system is implemented can further ensure that the hospital obtains the most value from the system. For example, the project administrator can help centralize requests for new system applications, expansion of the system to other facilities, etc.

Mary Schilder, director of information services consulting, WakeMed Health & Hospitals, said her organization works with RadarFind to accommodate thousands of location tags and temperature modules across multiple WakeMed facilities. RadarFind also communicates important information on a tagged item’s status to show whether it is in-use, available or needs cleaning and disinfection. Status information is particularly useful for Materials Processing Distribution staff to quickly locate IV pumps that need to be disinfected.

Ownership. RadarFind touches Nursing, Materials Management, Finance, Facilities Engineering and Information Services, plus other groups within a hospital. It was initially viewed as an IT- led initiative and having an Executive Champion other than the CIO was an issue.

Buy-in. We started off with a proof of concept focusing our efforts only on IV pumps. This created limited awareness of RadarFind and its capabilities.

Proof in the pudding. Getting the data to demonstrate ROI was initially a challenge.

While we changed the process to have the MPD staff slide the status tag to yellow upon arrival to the floor there was still some inaccuracy with use of the slide bar. Instead we looked for another metric to prove ROI. A monthly report provided to us from the IV pump rental company showed reductions in the use of rental pumps after RadarFind was implemented — about 20 percent.

Change Management. Once the buy-in came along and ROI was demonstrated, some needed process changes were initially slow to occur.

Cat’s out of the bag. Now the use of RadarFind and its benefit are widely known and there’s been a reaction to "tag everything."

Carl Story, director, distribution services, The Ohio State University Medical Center, and Bruce McPherson, manager, material systems, OSUMC, said their organization uses the Ekahau system that operates on the standard 802.11x wireless protocol. About five years ago when 802.11x was just developing, OSUMC set up a ZigBee wireless network that enabled you to plug into existing electrical outlets. The challenge? The network reduced the number of electrical outlets they could use for other equipment, Story told AHRMM attendees. People would pull out the ZigBee units and then forget where they left them, which interrupted the network, he added. A full proprietary network would have cost between $5 million and $7 million up front, but funding wasn’t available for it. So OSUMC decided to set up a medical grade network that spanned 55 buildings, 4 million square feet and 2,673 wireless access points that took three years and 100,000 man hours to achieve.

Reports. Key concerns involved location history, movement or zone alerts and asset dwell time. In fact, McPherson indicated, the trash area can be a dark zone.

Site survey. The site survey was painful, only from the standpoint of the amount of time it took to finally get into all the areas that were needed. Some spaces had to be backtracked to several times to finally gain access. This was more of an OSUMC hurdle, just trying to make the space available while the techs were onsite.

AD/LDAP. AD/LDAP, Active Directory is a convenience that would support the same login as is used for the Medical Center network. It has been an irritant that we have not been able to make it work, so everyone has their own individual login. However, it does not impact the overall functioning of the RFID system.

Managing equipment that goes out for repairs. Managing equipment repairs required a planned system. We remove the RFID tags from the equipment before it goes out for repair.

Proper IT support. This encompasses many facets of a partnership. We are reliant on IT for system backup, and restore if necessary, as well as custom reports at this time. Many smaller departments will rely on IT to support their RFID implementation needs. IT maintains the overall system, servers and software.

Lack of recognition by vendors in the industry. Many vendors are developing new equipment or new versions of upgraded equipment, and are not recognizing the value that an RFID radio [can add to] their equipment. If some of the heavily used portable equipment in our industry came equipped with a standard wireless radio, it would push the development and deployment of RFID in hospitals all across the country.

Funding. Funding for projects is always a challenge, especially today with the state of the economy, and uncertainty of healthcare.

System accuracy. At AHRMM, McPherson talked about "floor hopping," room-level accuracy and the distance between the reported and actual location. Sometimes a product would be shown on floor 8 but be one floor above or below it, he noted.

Calibration survey. Once the vendor loaded and configured the software, McPherson’s team went from building to building with a laptop and an active tag to talk to the network, communicating back and forth with the server. McPherson acknowledged that this is a very time-consuming process that took about four days to complete.

Jean Sargent, CMRP, FAHRMM, director, supply chain, USC Health Sciences, addressed what she experienced at her former facility, University of Kentucky Healthcare. Sargent and her colleague Christopher Petter, director of materials management at UK Healthcare, shared their journey on implementing RTLS with Ekahau in May 2009 with AHRMM attendees two months ago in Denver. "The challenges we faced were not insurmountable," she noted. "We were lucky."

Complete implementation of the wireless technology in all areas of the hospital delayed implementation in 10 percent-15 percent of the hospital.

We were unable to implement the technology at the smaller hospital as the wireless was not installed until much later.

Obtaining IT support with MAC addresses.

Lack of cooperation with clinical engineering placing the tags on the hospital beds. EVS was excited about knowing where the beds were being stashed. They also planned to use the information to acquire a bed closer to where it was needed.

Length of time for the RFP process.